What is the most interesting case you've seen in the ER?

FlyingScot, RN · Dec 4, 2011

I gotta know, what was Dr. N's reaction to THAT?

He stepped on his chair and leaped over the counter which is about 4 feet high. He looked like Batman but with a white cape (lab coat flying)!!!!

**NickiLaughs, ADN, BSN, RN** · Dec 6, 2011

This is the most interesting thread I think I've ever read, keep em coming!

Christy1019, ASN, RN · Dec 13, 2011

I'm ICU. This was really a nightmare but interesting case as well. This young teenager came in with a seizure. No history, CT/labs everything normal. And we seriously couldn't get the seizures under control. Intubated quickly to protect airway. Ativan, Dilantin, all the usual meds weren't working. He ended up getting transferred to a Level I Med Center. I can't imagine he did very well. We were suspcious of some rare disease as he was a foreign student spending a year abroad or that he had done some drug and short circuited.

I had a similar situation a few years ago, minus the pt being foreign, no hx of seizures, unable to control seizures in the resus room, after i think 10-12mg ativan w/in 30min he stopped thrashing but continued to have nystagmus for awhile afterward. he was eventually assigned to me in the monitored area, amazingly he was managing to maintain his own airway and was never intubated.

I was a newer nurse and when trying to assess him he was obviously so sedated there wasn't any way i could do a full neuro assessment etc but i noted that his pupils were pinpoint/non-reactive, GCS was honest to god 3 while continuing to maintain his own airway, and since i was newer i had asked our ER Pharmacist if the ativan or dilantin drip he was on would cause pinpoint pupils and he said no and that they should be pretty dilated from the seizure. so i check a u-etox which was negative for opiates, + for cocaine which if recently used would ALSO cause pupil dilation. head CT was clear, no obvious cause for the symptoms, and for the life of me i could not stimulate any sort of response from the patient with any painful stimuli. I asked the resident who was a cocky 3rd year that didn't think much of nurses, if he could just come assess him again, he came over said "well he's sedated what do you expect, his head CTs fine, i'm not worried" and walked away...

now i'm the type of person that HAS to have an explanation for things i can't figure out, and if google can't help me you can bet i'm gonna keep asking everyone questions until i get my answer lol. Luckily the oncoming midnight staff MD and resident were awesome Docs that i always respected and trusted their judgement and they were always willing to answer any questions i had. So I'm asking the staff what kind of neurological problems would cause pinpoint pupils when X, Y, and Z should all cause them to be fully dilated, and she says "Pontane infarct - brainstem stroke".. so i ask her to please come see this patient, explain what the other MD said and all of this investigating i've been doing lol, also point out to her that he had only been given a 250cc NS bolus, yet had put out 2 liters of urine in the past 45min... she immediately repeats the head CT, and gets the neurologist to the ER w/in minutes...

turned out the patient DID have a pontane stroke that was not picked up on initial CT d/t positioning and b/c it was the initial ischemic event, hadn't had time to become apparent on CT, the infarct then put him into SIADH where he just started dumping out urine by the liter... patient was admitted with poor prognosis, i don't know what happened to him and i don't know if earlier recognition would have made a difference, but now i will never forget what the staff MD told me.. PINPOINT=PONTANE (obviously not ALWAYS, but in absence of other causes it should be considered). to this day that staff MD and myself have a great working relationship, she trusts my judgement and appreciates that i won't just accept what i'm told by another doctor when my gut tells me otherwise.

sorry for the long post but your situation just brought me back to that patient, luckily haven't encountered that diagnosis again in my past 4years, but it's a good thing to keep in the back of your mind

Christy1019, ASN, RN · Dec 13, 2011

Creutzfeldt-Jakobs disease in a 50 yo female- she went from going out dancing with her friends to unable to eat/walk/talk and combative the next week...died after a couple more weeks. Brain looked like swiss cheese on ct/mri with the holes getting bigger and bigger...very sad.

oh holy hell.. (no pun intended, i apologize) i just googled several CT/MRI images of the progression of the disease through the scans... it literally scared and depressed me looking at them... :eek:

granted i did just take my lunesta and am relaxing after an awful night shift with a smirnoff ice.. so that could POSSIBLY explain why i'm scared of the picture LMAO :idea:

NO50FRANNY · Dec 14, 2011

Most interesting case for me was actually quite recently, A construction worker was carrying a metal bar near some train tracks and overhead lines- the electricity "formed an arc" through the patient- 20,000 Volts-No one saw this, his co-workers just heard the bang- not sure how far he was thrown. Large occipital haematoma- electricity entry point through his L) shoulder, and exited out his L) foot. Full thickness burn at exit site, partial thickness both legs and circumfrential L) arm with some superficial burns across his chest. You could see where his mobile phone had exploded on his L) hip and the shape of the batteries. When we inserted his catheter myoglobin came out which looked just like frank haematuria but wasn't. The best part of this story is that this lovely man was fully awake when he arrived and after a reasonable amount of ketamine was quite settled. He survived- was so great to see his adult sons and wife come in and talk to him. Paramedic special in this case as I am left wondering why they didnt deem it necessary to protect his c-spine, or think it humane to sedate him a little? Ive never heard of anyone surviving something like that. Very interesting.

**canoehead, BSN, RN** · Jan 2, 2012

I've done a thump, on a newly DNR patient whose family had been told he was going to die about 30 seconds earlier. Cardiologist at bedside, and the family was being ushered out. THUMP! They had another few hours to digest the news, and he passed later that night.

beachmom · Jan 4, 2012

A young woman was found unconscious in her jail cell. They brought her to the hospital where she started seizing. They tried but couldn't stop the seizures. Finally, they found the broken baggie of drugs in her lady parts.

She spent a couple weeks comatose in ICU. Everyone thought she would never wake up, but she actually improved. When she left the hospital she was talking a little and going to rehab. Never heard what happened regarding her arrest.

Roy Fokker, BSN, RN · Jan 4, 2012

* Middle-age person complaining of bilat-ankle pain. Zero cardiovascular complaints (SoB, n/v, CP) Had been mowing lawn on a hot, humid day. Was tachycardic on initial presentation with diaphoresis. Initially written off to 'hot humid day'. Despite multiple doses of pain meds, was still tachy (despite having zero pain now). "Let's get an EKG just to be sure".... STEMI!

* Young female presents to ED with complaint of low back pain x 1 week. She was horsing around at work on a chair with roller wheels, someone pushed a little too hard and she took a tumble. Further, detailed history reveals nausea with occasional vomiting. Pt. insisted has not been sexually active in over a year and last menstrual period was a month ago. Pt. unable to provide urine for HCG ("can't keep anything down", despite Zofran).... Lumbar X-ray reveals crowning fetus!

* Middle-aged pt. walks into ED with cc/o generalized "weakness" and "I feel tired all the time" x 2 weeks. No cardiovascular complaints. No significant medical history other than hypertension. Labs: K=1.1, Mag=0.4, CrCl= 12.1, and other labs I can't remember but were completely off the charts! Pt. had both PO and IV K and Mag - when I left off-shift, despite two doses of each, levels had barely improved!!

* Elderly gentleman sitting up talking to me in ED (walked in). Nonspecific and diffuse complaints ("I feel tired" and "I just don't feel right"). No known trauma period. No neuro deficits upon exam. Head CT showed massive bleeding - the left brain was pretty much all blood....

cheers,

RescueNinja · Jan 4, 2012

Young female presents to ED with complaint of low back pain x 1 week. She was horsing around at work on a chair with roller wheels someone pushed a little too hard and she took a tumble. Further, detailed history reveals nausea with occasional vomiting. Pt. insisted has not been sexually active in over a year and last menstrual period was a month ago. Pt. unable to provide urine for HCG ("can't keep anything down", despite Zofran).... Lumbar X-ray reveals crowning fetus![/quote']Was baby born living? Do you know the outcome?

thelema13 · Jan 6, 2012

1. Stroke alert by EMS, right side completely flaccid, blown right pupil, hypertensive 220's/130's, GCS of 8. We get a second call to have respiratory on standby because his O2 sats were dropping and they were going to intubate, ETA 5 minutes. They were unloading him from the ambulance, he suddenly jerked upright and vomited his ET tube out! As we are walking to CT the pt 'miraculously' recovers, NIH of 0, initial head CT negative. HTN resolved. Admitted for observation.

2. Middle aged hispanic woman, native Spanish speaker, with cold symptoms. She ambulated to the bathroom to give me a urine spec, and I hear a bloody curdling scream. Run in there, and there is a fetus's hand out of the woman lady parts. Terrible outcome, fetal demise and she was severely septic. WBC ~55k, H&H 6&14 and ARF to top it off. Don't know if she made it.

3. Mechanic comes in complaining of right hand numbness. Just worked 14 hours out in the Florida sun in July. No other s/s, hx of htn. Pt was flushed and thirsty. On a hunch, ran an EKG, he had 7mm of elevation, largest deflection I have ever seen. STEMI alert, straight to cath lab, ended up seeing him at the gas station 2 weeks later buying a 12-pack.

allnurses Guide · Jan 10, 2012

Stopped at a rollover, ejection. Car was about 50 feet down the road, upside down. One leg deformed, the other completely degloved: he had a sack of leg and skin still connected, including foot, off to the side, and straight down was clean white femur, knee and tib/fib, stopping at the ankle.

He was alive, shocky, but talking. Never found out what happened after the helicopter; we were on vacation in another state. My daughter wouldn't let me back in the car because of the blood (come on, it wasn't dripping!). Got washed off with the camp water jug, and had to change my pants in the middle of the highway median.

Roy Fokker, BSN, RN · Jan 14, 2012

Was baby born living? Do you know the outcome?

No idea. Sorry. She was sent to L&D right away.

It wouldn't surprise me if both Mom and baby made it ok...

cheers,